Clostridium difficile Ileitis in Pediatric Inflammatory Bowel Disease
On hospital day (HD) 1, oral antimicrobial therapy was changed to vancomycin (500 mg every 6 hours) because of vomiting, believed to be caused by metronidazole. Based on clinical and radiographic findings suggestive of small bowel obstruction, a catheter was placed in her stoma, her oral intake was restricted, and total parenteral nutrition was started. She developed fever to 38.5°C on HD 3 and began complaining about sore throat and sinus pressure, and was clinically diagnosed as having pharyngitis. Throat cultures for bacterial, viral, and fungal pathogens were negative. Epstein-Barr virus and cytomegalovirus serologies showed no evidence of acute infection. Repeat laboratory studies on HD 7 revealed increasing white blood cell count of 20.8 × 103/μL with 47% bands. Additional stool studies were obtained—including viral culture, Shiga toxin A antigen, and bacterial culture for Salmonella, Shigella, Yersinia, Escherichia coli 0157:H7, and Campylobacter—and all were negative. Following consultation with infectious diseases, IV metronidazole (10 mg/kg per dose q6 hours) was added to oral vancomycin for treatment of severe C difficile infection.
The patient's symptoms of possible small bowel obstruction were unchanged despite medical management; thus, the patient underwent ileostomy exploration and revision on HD 8. The surgeon identified pseudomembranous plaques that were limited to the dilated segment on direct visualization. The inflamed ostomy and adjacent dilated bowel segment were mobilized, explored, and resected. Histologic examination of the resected ileostomy and small bowel revealed focal erosion of the mucosal surface, mild villous atrophy, focal cryptitis, and rare crypt abscesses. The lamina propria showed increased plasma cells, histiocytic cells, and multinucleated giant cells within the submucosa. These findings were determined by the pathologist to be consistent with chronic active ileitis.